JANUARY

The U.S. Health Care System, 2015
The Commonwealth Fund
What is the role of government?
The Affordable Care Act (ACA), enacted in 2010, established “shared responsibility” between the government,
employers, and individuals for ensuring that all Americans have access to affordable and good-quality health
insurance. However, health coverage remains fragmented, with numerous private and public sources as well as
wide gaps in insured rates across the U.S. population. The Centers for Medicare and Medicaid Services (CMS)
administers Medicare, a federal program for adults age 65 and older and people with disabilities, and works in
partnership with state governments to administer both Medicaid and the Children’s Health Insurance Program,
a conglomeration of federal–state programs for certain low-income populations.
Private insurance is regulated mostly at the state level. In 2014, state- and federally administered health insurance
marketplaces were established to provide additional access to private insurance coverage, with income-based
premium subsidies for low- and middle-income people. In addition, states were given the option of participating
in a federally subsidized expansion of Medicaid eligibility.
Who is covered and how is insurance financed?
In 2014, about 66 percent of U.S. residents received health insurance coverage from private voluntary health
insurance (VHI): 55.4 percent received employer-provided insurance, and 14.6 percent acquired coverage
directly. 1 Public programs covered roughly 36.5 percent of residents: Medicare covered 16 percent, Medicaid
19.5 percent, and military health care insurance 4.5 percent (U.S. Census Bureau, 2014).
In 2014, 33 million individuals were uninsured, representing 10.4 percent of the population (U.S. Census Bureau,
2014). The implementation of the ACA’s major coverage expansions in January 2014, however, has increased
the share of the population with insurance. These reforms include: the requirement that most Americans procure
health insurance; the opening of the health insurance marketplaces, or exchanges, which offer premium
subsidies to lower- and middle-income individuals; and the expansion of Medicaid in many states, which
increased coverage for low-income adults. According to one survey, the rate of uninsurance among working-age
adults fell by 7 percentage points between March 2015 and September 2013 (Collins et al., 2015); another
survey found that 17.6 million previously uninsured people have acquired health insurance coverage (ASPE,
2015a). It is projected that the ACA will reduce the number of uninsured by 24 million by 2018 (CBO, 2015).
Public programs provide coverage to various, often overlapping populations. In 2011, nearly 10 million
Americans were eligible for both Medicare and Medicaid (the “dual eligibles”) (Henry J. Kaiser Family
Foundation, 2015a). The Children’s Health Insurance Program (CHIP), which in some states is an extension
of Medicaid and in others a separate program, covered more than 8.1 million children in low-income families
in 2014 (Medicaid.gov, 2014).
Undocumented immigrants are generally ineligible for public coverage, and nearly two-thirds are uninsured.
Hospitals that accept Medicare funds (which are the vast majority) must provide care to stabilize any patient with
an emergency medical condition, and several states allow undocumented immigrants to qualify for emergency
Medicaid coverage beyond “stabilization” care. Some state and local governments provide additional
coverage, such as coverage for undocumented children or pregnant women.
1
Estimates by type of coverage are not mutually exclusive; people can be covered by more than one type of health
insurance during the year.
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